Doctors use shortforms in writing medical records and there is nothing wrong in doing so. The problem is that due to absence of standard/accepted shortforms, these are capable of being misinterpreted or differently interpreted by courts, patients and other doctors. There is a need to standardize commonly used shortforms/abbreviations in medical practice. (In this case, the orthopedic surgeon (OP) had recorded "Comp. # B.B. of R Leg," the full form of which is "compound fracture on both bones of the right leg." Luckily, no one questioned whether "B.B" really meant "both bones," otherwise it would have added to the problems of the orthopedic surgeon (OP) as it is not a standard shortform.)

Doctors need to be extra careful in preparing their written defense in a case of medical negligence. The following is advisable:

Collect all the relevant medical records, check and recheck them, and then prepare your defense.

Ensure that complete facts are stated and any important aspect is not missed.

Check for inconsistencies between medical records and your written defense.(In this case, the orthopedic surgeon (OP) produced a prescription given to the patient during the first consultation in appeal, that is at a very delayed stage of the legal proceedings. Furthermore, this prescription was contradictory with the written defense filed earlier in the court. Obviously, this prescription proved to be counterproductive.)

Prescription must record the history of the patient, detailed description of the wounds, investigations advised, medicines prescribed, precautions advised, and so on. (In this case, the court drew adverse inference against the orthopedic surgeon (OP) for writing a prescription which was devoid of the advice to perform X-ray, details of fracture, and further treatment. The court held that this was against accepted medical practice.)

Advice and perform the appropriate investigations when indicated. (In this case, the orthopedic surgeon (OP) was held negligent for not advising X-ray to the patient who had met with an accident during the first consultation but about 2 weeks later.)

Facts of the case

The patient who had met with an accident consulted the orthopedic surgeon (OP) who applied plaster on his right leg. The patient sued the orthopedic surgeon (OP) for negligence later.

Doctor's defense

It was stated in defense by the orthopedic surgeon (OP) that, when he examined the patient on the first day, an X-ray was taken and a compound fracture of both the bones of the right leg was diagnosed. The orthopedic surgeon (OP) produced prescription dated 20.1.2000 wherein it was recorded "Comp. # B.B. of R Leg," the full form of which is "compound fracture on both bones of the right leg." However, this prescription was produced in the appeal and not while filing the original defence in court.

Findings of the court

The court found that, in the written defence filed in court by the orthopedic surgeon earlier, he had stated that on 20.01.2000 when he was consulted for the first time, there was one wound and swelling on the right leg, he had therefore given treatment for reducing swelling and during the next consultation on 05.02.2000, X-ray of the right leg was taken which reported that both the lower part of the bones of right leg were fractured and plaster was done as the swelling was reduced. Subsequently, in appeal, the orthopedic surgeon (OP) produced a prescription dated 20.01.2000 before the court wherein it was recorded that he had examined the patients X-ray on 20.01.2000. The court observed that from the aforesaid it was clear that the first X-ray was taken on 05.02.2000 and the prescription dated 20.01.2000 was false.

The court found that, after the first consultation, the patient had gone to the orthopedic surgeon (OP) on 26.01.2000, 29.01.2000, and finally on 05.02.2000 when X-ray of the right leg was taken. The court observed that the orthopedic surgeon (OP) should have advised an X-ray during the first consultation on 20.01.2000 and not after full two weeks, i.e., on 05.02.2000.

The court drew adverse inference as the prescription dated 20.01.2000 was devoid of any instruction about the X-ray, details of wounds, fracture of the bones, bleeding points, etc., or instructions about plaster, contrary to the accepted medical practice.